Snapshot A 15-year-old boy with a history of Crohn disease who is on infliximab presents with a new rash. He reports pain preceding a new pink rash with tiny white “dots” all over his back. He has been taking infliximab for 1 year now and without issue. On physical exam, there are dozens of 1 mm pustules overlying erythematous skin with no scaling. A bacterial swab of the pustules reveal only normal skin flora. He is diagnosed with pustular psoriasis induced by infliximab. He is immediately started on other systemic therapy for both his Crohn disease and pustular psoriasis. Introduction Clinical definition idiopathic and chronic inflammatory disease characterized by hyperkaratosis and parakeratosis Classification plaque psoriasis most common well-defined erythematous plaques with scales typically over extensor surfaces inverse/intertriginous psoriasis plaques with minimal scaling in skin folds pustular psoriasis pustules rather than plaques erythrodermic psoriasis generalized erythema covering almost entire body surface area a medical emergency guttate psoriasis 1- 10 mm pink macules with scaling Epidemiology incidence US incidence 2% of population demographics normally, > 40 years of age but can affect people of all ages risk factors smoking skin trauma alcohol abuse stress cold weather Etiology idiopathic drugs while tumor necrosis factor-alpha (TNF-α) inhibitors are a treatment for psoriasis, it can cause new-onset “paradoxical” psoriasis when used for another inflammatory disease (such as Crohn disease) β-blockers may exacerbate psoriasis Pathogenesis hyperproliferation of basal stem keratinocytes ↑ inflammation, especially inflammatory markers IL-6, C-reactive protein, TNF-α, E-selectin, and ICAM-1 Associated conditions psoriatic arthritis Presentation Symptoms painful or pruritic skin lesions joints may be painful or stiff especially in feet and hands Physical exam plaque psoriasis well-circumscribed, pink papules and flat-topped plaques with silvery scales common locations scalp trunk buttocks extensor surface of limbs positive Auspitz sign when scales are scraped off, there is pinpoint bleeding results from exposure of dermal papillae nail changes pitting candle-grease sign when a sharp object is used to scratch a lesion, a candle-grease-like scale can be produced Koebner's phenomenon psoriatic lesions appear at site of cutaneous physical trauma pustular psoriasis sterile pustules on erythematous skin guttate psoriasis salmon pink papules with fine overlying scales location trunk proximal extremities Studies Labs electrolytes there may be electrolyte imbalances if psoriasis is erythrodermic Histology acanthosis with parakeratosis (thickened stratum corneum with preserved nuclei) hyperkeratosis (thickened epidermis) Munro microabscesses ↑ stratum spinosum ↓ stratum granulosum Diagnostic criteria diagnosis is primarily based on clinical exam and history Differential Atopic dermatitis Seborrheic dermatitis Treatment Conservative emollients indications for all patients Medical topical corticosteroids indications first-line and often used in combination with topical calcipotriene note that systemic steroids are avoided due to likely flare up of psoriasis while tapering topical calcipotriene (vitamin D analog) indication first-line and often used in combination with topical corticosteroids systemic non-biologic therapies indications moderate-to-severe psoriasis used in combination with topical therapies drugs acitretin methotrexate cyclosporine apremilast especially for those with psoriatic arthritis as well systemic biologic therapy indication moderate-to-severe psoriasis drugs tumor necrosis factor inhibitors adalimumab etanercept infliximab anti-interleukin agents brodalumab secukinumab ustekinumab narrowband ultraviolet B indication for patients who are contraindicated to systemic therapy or who want to avoid systemic side effects Complications Cardiovascular disease psoriasis patients are at higher risk
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M3.DM.16.31) A 34-year-old woman presents to the clinic complaining of a rash that appeared on her left forearm after a scratch three days ago. This is not the first time she has experienced such a rash, as the patient states she had a similar looking lesion on her elbows three years ago. Upon further questioning, she states that her older sister has had problems with her skin, but she is unsure of the diagnosis. On physical exam you find a circular and scaly, pearl-colored rash superimposed over an abrasion on her left forearm (Figure A). Of note, the patient has has the following nail appearance (Figure B). What is the diagnosis in this patient? QID: 102785 FIGURES: A B Type & Select Correct Answer 1 Hypertrophic scar 0% (0/4) 2 Abrasion 0% (0/4) 3 Psoriasis 100% (4/4) 4 Lichen planus 0% (0/4) 5 Seborrheic dermatitis 0% (0/4) M 10 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (M3.DM.15.40) A 44-year-old man presents to his family physician with complaints of dry and scaly lesions on his bilateral elbows. He reports that these lesions developed in his 20's and have been growing in size since that time. He also reports similar lesions on the anterior portion of his knees. The lesions itch and they bleed when he scratches them. He denies any additional past medical history. Physical examination reveals the lesions shown in Figure A. Additional findings include pitting of the fingernails. Which of the following medications may worsen or exacerbate this patient's condition? QID: 102794 FIGURES: A Type & Select Correct Answer 1 Infliximab 36% (4/11) 2 Losartan 0% (0/11) 3 Oxycodone 9% (1/11) 4 Procainamide 0% (0/11) 5 Propranolol 27% (3/11) M 11 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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